After a teenager's suicide attempt, her desperate and bewildered parents dragged her to a mental health clinic. The 16-year-old admitted to drinking nearly every day and using an assortment of other illicit drugs. Only after a month in treatment did the clinician learn that the teenager had been molested when she was 8 years old by an uncle and threatened with death if she ever told her parents.

Oscar Bukstein, M.D., associate professor of psychiatry at the University of Pittsburgh School of Medicine, Western Psychiatric Institute and Clinic, and principal author of Practice Parameters for the Assessment and Treatment of Children and Adolescents with Substance Use Disorders, explained that often there is a high rate of anxiety disorders, including posttraumatic stress disorder, among adolescent substance abusers.

"While there may be other factors operating in the individual adolescent [that] promote substance use, exposure to trauma may be a component," he said.

The practice parameters that Bukstein developed with the Work Group on Quality Issues for the American Academy of Child and Adolescent Psychiatry emphasize that comorbidity is the rule, rather than the exception, in adolescents.

"We know that many children and adolescents have comorbidity, be it depression or disruptive behavior disorders, such as attention-deficit/hyperactivity disorder or conduct disorder," Bukstein said. "Many adolescents have ADHD, plus depression, plus substance abuse problems. Oftentimes, you need poly-pharmacy to help these kids. But clearly you need other treatments as well, and a multimodal approach...should be considered a standard of care."

The substance use disorders parameters, which were published with nine other practice parameters as a supplement to the Journal of the American Academy of Child and Adolescent Psychiatry (October 1997), are designed to orient clinicians, including child and adolescent psychiatrists, as to what substance use disorders in children and adolescents are all about.

"That, of course, includes their presentation, appropriate assessment procedures and appropriate treatment strategies," said Bukstein.

Few adolescents will volunteer that they may have a substance use problem.

"With any disorder dealing with deviant behavior, whether it be substance abuse or conduct disorder, the kids are usually trying to hide that behavior or get away with it. Very few have a reasonable amount of insight into the destructive nature of their problem. They rarely seek treatment on their own," Bukstein said. "Oftentimes, parents and others need to be tough and use whatever leverage they have to compel adolescents into treatment. To be honest, that is commonly the case with adults as well-only pressure and leverage from bosses, family and friends compels them into treatment."

With the University of Michigan's Monitoring the Future Study (1995) reporting that 30% of high school seniors have more than five drinks in a row in a two-week period and that an estimated 40% of high school students have tried an illicit drug (mostly marijuana), Bukstein was asked how clinicians could differentiate young people who use alcohol and other drugs experimentally from those who have a problem.

"About 90% of kids will have had at least one experience with alcohol before they leave high school, which makes some experimental use of alcohol pretty normative. What happens developmentally is that many of them mature and find they no longer enjoy drinking at that level. It is the kids who begin to have problems in one or more areas of their lives who should be targeted for assessment," Bukstein said. "In order to have any psychiatric disorder, you have to display either a clinically significant level of dysfunction or distress. So kids have to show difficulty in dealing with their families, their friends, functioning in school. If an adolescent by all counts seems to be all right, but is caught and acknowledges some substance use, it is substance use and not necessarily a substance use disorder. That is not to say that people should not be vigilant. Obviously, you have to use substances to have a substance use disorder. Therefore, it is something for parents and others to watch."

Risk Factors

An assessment of risk factors for substance use or abuse often can contribute to the index of suspicion.

"The clinician should inquire, with both the adolescent and his or her parents, about individual, family, peer and community risk factors," according to the substance use disorders parameters.

"Attention-deficit/hyperactivity disorder, particularly in the presence of other disruptive behavior disorders such as conduct disorder, makes a child a very high risk," Bukstein said. And certain temperamental traits, such as irritability, high motor activity, impulsivity, and a few others that we may not [have] had a chance to recognize in our research, may place a child at higher risk for substance use."

Parental abuse of substances, lack of close attachment with parents and lack of parental supervision, including inadequate parental management styles, are among the family risk factors.

"Research indicates that substance use disorders do run in families. According to twin and adoption studies, we know there is a significant genetic component to that. Obviously, though, there are environmental factors that shape that biologic or genetic risk.

"Kids who have early attachment with peers seem to be more at risk for developing substance use disorders, as are kids with friends who abuse substances," Bukstein said.

Community or neighborhood characteristics, such as low socioeconomic status, high population density, physical deterioration of the neighborhood and high crime, are associated with greater adolescent substance use.